Applied Psychology OPUS

“The Walking Wounded”: Here-and-now Coping Strategies to Ease the Reintegration of American Military Veterans

Kara Duca

Since 2001, approximately 2.4 million troops have been deployed to warzones in Iraq and Afghanistan, and over half of these troops have now returned to civilian life (U.S. Department of Veteran Affairs, 2012). Although veterans often feel a deep sense of relief and joy at the prospect of returning home, the journey back to a civilian life is all but smooth (Demers, 2011; Doyle & Peterson, 2005). The process of reintegration – that is, the return home, reunification with one’s family and community, and reentry into civilian life – is difficult for veterans who have spent` time in a foreign and life-threatening war zone (Doyle & Peterson, 2005). Although researchers and civilians acknowledge common struggles such as Post-Traumatic Stress Disorder (PTSD), depression, and suicidality, they often fail to recognize the challenges of reintegration, which include a crisis of identity and feelings of alienation (Demers, 2011). These additional stressors make returning home a difficult and even harrowing experience, instead of a welcomed relief.

One of the consequences of the dramatic shift in context that accompanies discharge is an intense identity crisis (Demers, 2011; Turner, 1974). The challenge of reconciling military and civilian identities parallels the experience of acculturative stress in immigrants to the United States. Acculturative stress refers to the psychological challenges that immigrants experience due to differences between home and host culture (Berry, 1997), and it can have a strongly negative impact on identity and mental health (Berry, 1990; Berry, Kim, Minde, & Mok, 1987). After spending months or even years in a military environment that is radically different from mainstream American society, military veterans often experience a reverse culture shock upon return to the U.S. that is analogous to the acculturative stress of immigrants (Berry, 1997). Thus, the reintegration experience provides support for the acknowledgement of military veterans as hidden immigrants, native-born Americans who spend a significant portion of their lives abroad and then return to the United States (Bell, 1997; Doyle & Peterson, 2005). Because they are legally Americans, mainstream society sees them as part of the established American culture and assumes a seamless reintegration. Despite their American status, these hidden immigrants endure a process very similar to that of first-time immigrants to the United States (Bell, 1997), with added stress of such high expectations for reassimiliation.

Whereas acculturative stress often influences the development of mental health symptoms in immigrants, reintegration stressors often exacerbate preexisting mental health symptoms in veterans. Mental disorders are the preeminent cause of medical discharge among men in the military (Keane, Niles, Otis, & Quinn, 2011). After discharge, veterans are highly susceptible to PTSD, anxiety, depression, anger symptomology, and substance abuse (Tanielian & Jaycox, 2008). Perhaps most striking is the recent dramatic rise in military suicides. Prior to the wars in Afghanistan and Iraq, the rate of suicide within the military was 25% lower than the rate of suicide among civilians (Hoge & Castro, 2012). Between 2005 and 2009, however, suicides within the Army and Marines doubled, and now outnumber civilian suicides. As a result, the total number of military suicides each year exceeds the number of combat-related deaths (Hoge & Castro, 2012). These mental health symptoms do not exist in the vacuum of the war zone, but follow survivors home, often adding stress to their relationships with family and friends (Demers, 2009). Reintegration challenges compound these mental health issues, making the process of returning home difficult and potentially dangerous for veterans and their families.  

The military has acknowledged these concerns. Every branch of the military imposes a mandatory reintegration training program prior to discharge, which addresses topics such as interpersonal relationships, employment, education, access to benefits, and the search for meaning and purpose in life (Sayers, 2011). Troops are also required to complete suicide awareness training while on active duty and mental health screens prior to and immediately following deployment (Doyle & Peterson, 2005; Hoge & Castro, 2012). Studies have questioned the effectiveness of these formalized programs, considering the widespread stigma surrounding mental health difficulties and treatment within military culture (Greene-Shortridge, Britt, & Castro, 2007). Soldiers often feel that admitting mental health symptoms and seeking treatment would expose a serious weakness, and fear discrimination and a decrease in respect from their peers (Greene-Shortridge et al., 2007). Because of this stigma, most of the troops who have the greatest need will never seek treatment (Greene-Shortridge et al., 2007). The inconsistency of research on existing mental health awareness programs within the military reveals a gap in the current understanding of reintegration challenges and the inhibiting force of stigma.

Existing studies rarely focus on mental health stigma in the military, and more often relegate it to a limitation in the discussion. Researchers put forth impassioned calls for policy changes and program development to reduce mental health stigma, but such large-scale transformations in perception and policy cannot occur overnight. In the meantime, rates of suicide, PTSD, and other mental health disorders are increasing at a frightening rate, and most of the affected military members will not seek or participate in treatment. Herein lies the question: What can we do in the meantime? What are some here-and-now methods for coping with reintegration difficulties for American military veterans? Because the War on Terror has precipitated the recent rise in military mental health symptoms, for the purposes of this review “American military veterans” will refer only to those who have served in Iraq or Afghanistan.

Navigating Reintegration: Facing the Identity Crisis

The world of soldiers is strikingly different from the world of civilians, and the individual soldier is a different person in each of these contexts. The role of boot camp is to strip military recruits of their former civilian identity and replace it with a new military identity (Demers, 2011). During this process, the soldier goes through three stages of identity change (i.e., Separation, Liminality, or “betwixt and between,” and Incorporation) in much the same way that immigrants to the United States undergo a dramatic identity transformation (Demers, 2011). Once this transformation is complete, the man has now become the soldier, and this new identity pervades his sense of self. Having this military identity benefits soldiers within the military context and particularly in war, where adhering to values of duty, honor, loyalty, and commitment and learning how to turn off emotions and depersonalize the act of killing can mean the difference between life and death (Demers, 2011). The military identity mandates total obedience to authority and the willingness to sacrifice oneself for others, and works off of a merit-based rewards system (Collins, 1998). These collectivistic and civic-minded values starkly contrast with those of the dominant American culture, which prioritize individualism and material gain (Demers, 2011). Researchers refer to this chasm between cultures as the “civil-military cultural gap” (Collins, 1998, p.216). Although the civil-military cultural gap is helpful in separating civilian from soldier upon enlistment, it also provides an understanding of the difficulties that accompany reintegration.

When soldiers are discharged from the military, they again undergo a radical identity shift from separation to integration. Oftentimes, however, they can become stuck in the “betwixt and between” phase of liminality, where they feel as if they are lost, belonging to neither military nor civilian culture (Demers, 2011; Turner, 1974). This process often leaves soldiers in limbo, attempting to live in the space between their two cultures. At this juncture, social support from family and friends is critical to successful identity achievement. The American status of veterans, however, precludes family and friends from instinctual consideration of the difficulties that they face in realigning their split identities. Soldiers have described returning home and feeling like a killer inside, only to encounter family expectations that they act like a gentleman (Demers, 2011). This gap in understanding is not the result of any conscious decision to withhold support. Rather, civilians are relatively uneducated about the negative experiences that accompany reintegration and expect their soldier to return the same person as when he left, and are thus surprised and distressed when the reality is different (Doyle & Peterson, 2005). With education, however, it might be possible for family members to adjust their at-home strategies in order to support a positive resolution to their veterans’ identity crisis.

Research suggests that both veterans themselves and their surrounding social networks can employ certain dialogical strategies in order to effectively integrate military identity with civilian identity upon reintegration. O’Sullivan-Lago, de Abreu, & Burgess (2008) call for the adoption of an “I as a human being” strategy of living and speaking, which strengthens connections with others by focusing one’s attention on sameness rather than difference. This strategy of engagement supports veterans in facing and accepting their past experiences, which in turn allows for more effective negotiation of cultures and the rejection of any unwanted identities (Demers, 2011; O’Sullivan et al., 2008). From this point, veterans can work toward the development of a healthy hybrid identity in which their two selves coexist without any one claiming dominance over the whole person (Mahalingam, 2008). In contrast, the typical response has been “hegemonic bargaining,” in which the dominant (US) and former (military) cultures exist and compete within the individual for total expression (Chen, 1999). When others focus on differences rather than similarities between their experiences and those of their veteran, it perpetuates a split identity and leaves veterans at risk for mental health symptoms including depression and suicide vulnerability (Demers, 2011). Thus, it is beneficial for family members and other sources of social support to focus on connection by adopting an “I as a human being” strategy of relation and connection and encourage their veterans to do the same.

The Benefit of Narratives

In addition to adopting certain beneficial strategies of interpersonal relation, research suggests that drawing upon narratives may be another here-and-now strategy for effectively negotiating identity development (Demers, 2011). Because traumatic experiences add a challenge to forming and maintaining a cohesive identity, retelling narratives of those experiences helps to reconcile the disparate parts of one’s identity (Burnell, Hunt, & Coleman, 2009). For narratives to be helpful, however, they must first contain a theme. In addition, veterans should avoid dysfunctional integration – that is, telling their story in such a way as to solidify the traumatic experience into his/her identity to the extent that they begin to view all other experiences in relation to the traumatic experience (Demers, 2011). They should learn to frame the story as just one experience that is contextualized within their larger life. In this way, retelling one’s story can serve as an effective here-and-now coping strategy that aids in facilitating identity coherence (Burnell et al., 2009). These practices create a shared sense of meaning that can be helpful both in reducing veterans’ internal stress and fostering increased family cohesion (Holloway, 2010). Because family and community members often have a difficult time understanding and relating to veterans’ experiences, retelling stories could also serve to increase their understanding of the military experience and the struggles that reintegration provides. Such an understanding can lead to stronger social support networks and narrow the civil-military cultural gap (Demers, 2011). More than just a byproduct, however, this increase in knowledge and appreciation of veterans’ experiences may provide additional benefits for veterans, as a lack of understanding on the part of both family and community often introduces its own stressors to the reintegration process.

Narrative structures are beneficial primarily for their ability to assist veterans in reconciling a split identity and finding sources of inner strength and pride (Holloway, 2010). However, these inner transformations must occur in the context of a society that supports veterans and assumes responsibility for reintegration (Holloway, 2010). In contrast to the highly visible popular support of soldiers during World War II, the wars in Iraq and Afghanistan have seen a noticeable decline in popular support of soldiers (Doyle & Peterson, 2005). The absence of a national consensus concerning the war itself, unfortunately, has expanded to a lack of validation and respect for soldiers as well as a general non-acknowledgement of returning veterans (Doyle & Peterson, 2005). Families of soldiers have expressed frustration when they attempt to talk with others about the emotional and psychological stress that comes with loving a soldier, and find that others respond by refocusing the discussion on the politics of the war (Demers, 2009). Such a fragmented and unsupportive social context disallows veterans and their families from producing and sharing effective narratives. By acknowledging and validating soldiers’ efforts and identifying with the emotional aspects of a soldier’s experience that are universal and inherently human (Holloway, 2010), society can better provide effective support and connection in the midst of an otherwise isolating experience.

In addition to the general lack of societal consensus on the politics surrounding the wars in Iraq and Afghanistan, the dependence on an all-volunteer military force as opposed to a draft has granted Americans the opportunity to completely detach from military issues, exacerbating the lack of understanding about the considerable differences between the two worlds (Collins, 1998). Veterans have described feelings of being misunderstood and disrespected by civilians who did not understand who they were or what they had endured (Demers, 2011). Coming from a context in which they worked hard, earned the respect of their peers, were highly trained and capable, served as leaders, and filled with a sense of purpose, veterans return home to a society that has no clear role for them (Demers, 2011; Holloway, 2010). The increased distance between veterans and civilian society perpetuates a split identity in veterans and hinders the development of a holistic healing process.      

Acknowledgement of Psychological Wounds

Although researchers, mental health professionals, and civilians are beginning to understand the physical and psychological wounds that plague veterans, they often fail to acknowledge the impact of war on a soldier’s emotional processes. Holloway (2010) calls for an increased awareness of emotional wounds of war in both military culture and the larger society, suggesting that such an awareness might lead to more holistic social support for returning service members. Drawing on the disciplines of psychology and mythology, she contends that “the soul can experience a violent ‘rupturing’ just like a leg, a lung, or a blood vessel in the brain” (Holloway, 2010, p.184). The Western penchant for immediately medicating not only veterans’ physical wounds but their psychological and emotional wounds as well, precludes an understanding of emotional wounds and robs veterans of the opportunity to heal their souls (Holloway, 2010). Because of this emphasis on Western medical treatment, American society offers few support systems that address the struggles of reintegration from a soulful healing perspective. Holloway draws on the mythical tradition of the Wounded Hero to re-vision the soldier’s experience from a more holistic perspective, and draws parallels between ancient myths and the contemporary soldier’s experience. Most notably, the Wounded Hero must undergo a difficult journey in order to discover meaning in his life and understand his role in the world (Holloway, 2010). When the hero reaches the end of his journey, it remains vital for him to draw upon sources of social support rather than isolate as he navigates a period of uncertainty and confusion.

Social support is vital in addressing many of the spiritual wounds that veterans encounter. One of the most pervasive setbacks that veterans experience is a perception of failure or weakness. Many soldiers return with Survivor’s Guilt, or feelings of guilt about leaving friends in the war zone coupled with inability to understand why they are still alive when so many others (in many cases, many of their close friends) were killed or seriously wounded (Greene-Shortridge et al., 2007). In these cases, social support serves the vital purpose of helping the veteran to reconcile the disparity between his perception of himself as weak and a failure and the reality of his traumatic experiences (Holloway, 2010). Just as the fear of appearing weak inhibits soldiers from seeking out support for particular mental health symptoms, so too does it prevent them from acknowledging and attending to their broken spirit. Without adequate social support, veterans react to these internal ruptures with a combination of shame, guilt, and stoicism (Holloway, 2010), patterns that simply maintain their current negative responses. By reframing the soldier’s experience as a journey rather than an isolated experience and assuming a soulful healing perspective, however, society can more effectively aid veterans in achieving a more holistic and comprehensive reintegration.

Western practice typically addresses psychological wounds of war using the same healing techniques it would with any other physical injury, following the medical model of diagnosis, medication, and intermittent follow-ups (Holloway, 2010). However, the uniquely traumatic wounds of war are more than just physical; these wounds also occur on psychological, social, emotional, and spiritual levels. The veteran returns in such a complex state that it is necessary for a holistic and comprehensive healing modality to be able to address all of these concerns and treat the whole person instead of each individual “problem.” Future research would greatly benefit from an exploration of ways to develop such holistic modalities. Researchers are beginning to experiment with atypical approaches, such as including spiritually inspired language in both medical and therapeutic settings, that could serve to bring together varied aspects of a veteran’s issues (Holloway, 2010). Though knowledge in this area is extremely limited, it is clear that the one-size-fits-all approach to such multi-layered and complex traumas is only a temporary fix for a larger issue, a Band-Aid on a gunshot wound. Western society’s reliance on medical models of treatment neglects the damaging effect of war on a veteran’s psyche and soul, and precipitates veterans’ negative self-image of being “broken” (Holloway, 2010). The challenges of reintegration are great, though they are by no means insurmountable. While researchers and policymakers struggle to eradicate the pervasive stigma associated with mental health treatment in the military and improve reintegration training programs, family and friends can employ simple strategies such as humanistic identification, encouragement of narratives, and an appreciation of the soldier’s experience in order to buffer the negative consequences of reintegration and help their veteran move forward with a new identity and sense of purpose.

 

References

Bell, L. (1997). Hidden Immigrants: Legacies of growing up abroad (Vol. 11). Notre Dame, IN: Cross-Cultural Publications.

Berry, J. W. (1990). Psychology of acculturation. In J. J. Berman (Ed.), Nebraska symposium on motivation: Vol. 37. Cross cultural perspectives. Current theory and research in motivation (pp. 201-234). Lincoln: University of Nebraska Press.

Berry, J. W. (1997). Immigration, acculturation, and adaptation. Applied Psychology: An International Review, 46(1), 5-68.

Berry, J. W., Kim, U., Minde, T., & Mok, D. (1987). Comparative studies of acculturative stress. International Migration Review, 21, 491–511.           

Burnell, K. J., Hunt, N., & Coleman, P. G. (2009). Developing a model of narrative analysis to investigate the role of social support in coping with traumatic war memories. Narrative Inquiry, 19(1), 91-105.

Chen, A. S. (1999). Lives at the center of the periphery, lives at the periphery of the center: Chinese American masculinities and bargaining with hegemony. Gender and Society, 13(5), 584-607.

Collins, J. (1998). The complex context of American military culture: A practitioner’s view. Washington Quarterly, 21, 213-226.

Demers, A. (2009). The war at home: Consequences of loving a veteran of the Iraq and Afghanistan wars. Internet Journal of Mental Health, 6(1), 3-20.

Demers, A. (2011). When veterans return: The role of community in reintegration. Journal of Loss and Trauma, 16, 160-179.

Doyle, M. E., & Peterson, K. A. (2005). Re-entry and reintegration: Returning home after combat. Psychiatric Quarterly, 76(4), 361-370.

Greene-Shortridge, T. M., Britt, T. W., & Castro, A. (2007). The stigma of mental health problems in the military. Military Medicine, 172(2), 157-161.

Hoge, C. W., & Castro, C. A. (2012). Preventing suicides in US service members and veterans: Concerns after a decade of war. Journal of the American Medical Association, 308(7), 671-2.

Holloway, S. D. (2010). The Wounded Hero: Supporting military families through mythology and the performing arts (Doctoral dissertation, Pacifica Graduate Institute). Retrieved from web.

Keane, T. M., Niles, B. L., Otis, J. D., & Quinn, S. J. (2011). Addressing post-traumatic stress disorder in veterans: The challenge of supporting mental health following military discharge. In T. M.

Keane, B. L. Niles, J. D. Otis, & S. J. Quinn (Eds.), Deployment psychology: Evidence-based strategies to promote mental health in the military (pp. 243-273). Washington, DC: American Psychological Association.

Mahalingam, R. (2008). Power, social marginality, and the cultural psychology of identities at the cultural contact zones. Human Development, 51, 368-373.

O’Sullivan-Lago, R., de Abreu, G., & Burgess, M. (2008). ‘I am a human being like you’: An identification strategy to maintain continuity in a cultural contact zone. Human Development, 51, 349-367.

Sayers, S. L. (2011). Family reintegration difficulties and couples therapy for military veteran and their spouses. Cognitive and Behavioral Practice, 18, 108-119.

Tanielian, T, & Jaycox, L. (Eds.) (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation.

Turner, V. (1974). Dramas, fields, and metaphors: Symbolic action in human society. Ithaca, NY: Cornell UP.

U.S. Department of Veteran Affairs. (2012). Analysis of VA health care utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans. Retrieved from http://www.publichealth.va.gov/docs/epidemiology/healthcare-utilization-report-fy2012-qtr1.pdf